Pupil sparing 3rd nerve palsy

 SHORT CASE

B.MADHU KUMAR

1701006016


PUPIL SPARING 3RD NERVE PALSY

A 45 year old female tailor by occupation came with

c/o headache with dragging sensation in the eyeballs since 3 days


Dropping of eyelid since 1 day


Double vision in the right eye since 1day


Vomitings since 3 days




HOPI: patient was apparently asymptomatic 1 month back.then she had diminision of vision for which she went to a ophthalmologist in nalgonda, they prescribed glasses for her eyesight. Then after using them for few days she got severe headache with dragging sensation in both the eyeballs. She went to a hospital in suryapet and was prescribed by pain killers.


Then next day she developed swelling of right eye, drooping of eyelid, double vision in right eye and vomitings since 3 days which was non bilious, non projectile 




No h/o sudden onset weakness of limbs 


No h/o any dizziness




Not a k/c/o DM, HTN, TB , ASTHMA, CVA, CAD




GENERAL EXAMINATION:




patient is c/c/c


No pallor, no icterus, cyanosis, clubbing,koilonychia lymphadenopathy.




VITALS: 


Temperature: 98.6


Bp:130/90 mmhg


PR:56


RR: 20


Spo2: 99 on RA


Gcs:E4V5M6




CVS : S1 S2 heard 


RS: BAE+


P/A: soft, non tender




CNS EXAMINATION:


Speech normal


Pupils normal 




Cranial nerve -3 


Left : normal


Right: lateral rectus+


           Medial rectus -ve


           Superior rectus -ve 


           Inferior rectus -ve 


Sensory 6th intact


Other cranial nerves - intact




              


Tone : Rt Lt


          UL Normal Normal


          LL Normal Normal




Power: Rt Lt


         UL 5/5 5/5


         LL 5/5 5/5




Relfex:     


                     Rt Lt


            B - +2 +2


            T - +2 +2


            S- +2 +2


            A - +2 +2


            K - +2 +2


            


P- Flexor Flexor 




neck stiffness -ve


Gait - normal 




Investigations:













Diagnosis: pupil sparing 3rd nerve palsy




TREATMENT: 


1. IVF - NS, RL @100ml/hr


2.INJ PAN 40mg IV/OD


3.INJ CIPLOX 200mg IV/BD


4.INJ METROGYL 100ml IV/TID


5.INJ ZOFER 4mg/IV/TID


6.INJ DICLOFENAC 75mg(3cc) IM/BD


7.VITALS MONITORING 4th hrly


8.INFORM SOS




13/5/22


S- no fresh complaints


O- right eye ptosis , mild conjuctival congestion 


H/o lid swelling+, monocular diplopia, retropulsion+


Orbital movements: 


rightt eye- abduction +


Left eye- all movements +


CN-3 no right lid elevation/medial rotation


Vitals:


Temp-afebrile


PR: 65


RR: 18


BP: 100/60




CVS-s1s2+


RS - BAE+


P/A- soft, non tender




A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME




P-  


1. INJ METHYLPREDNISOLONE 1gm /IV OD IN 100ml NS


2.INJ PAN 40mg IV/OD


3VITALS MONITORING 4th hrly


4.INFORM SOS






14/5/22 day 3


S- no fresh complaints


O- right eye ptosis , chemosis resolved 


lid swelling resolved, monocular diplopia, retropulsion+


Orbital movements: 


rightt eye- abduction +


Elevation,depression,adduction,intorsion -absent


Left eye- all movements +


CN-3 no right lid elevation/medial rotation


Vitals:


Temp-afebrile


PR: 58


RR: 18


BP: 110/70




CVS-s1s2+


RS - BAE+


P/A- soft, non tender




A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME




P-  


1. INJ METHYL PREDNISOLONE 1GM in 100 ml NS OD


2.INJ PAN 40mg IV/OD


3.VITALS MONITORING 4th hrly


4.INFORM SOS

15/5/22 day 4


S- no fresh complaints


O- right eye ptosis , chemosis resolved 


lid swelling resolved


Ptosis +


Orbital movements: 


rightt eye- abduction +


Elevation,depression,adduction,intorsion -absent


Left eye- all movements +


Vitals:


Temp-afebrile


PR: 64


RR: 18


BP: 160/80




CVS-s1s2+


RS - BAE+


P/A- soft, non tender




A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME




P-  


1. INJ METHYL PREDNISOLONE 1GM in 100 ml NS OD


2.INJ PAN 40mg IV/OD


3.INJ HAI s/c acc to grbs


4.VITALS MONITORING 4th hrly


5.INFORM SOS






16/5/22 day 5


S- no fresh complaints


O- right eye ptosis , chemosis resolved 


lid swelling resolved


Ptosis +


Orbital movements: 


rightt eye- abduction +


Elevation,depression,adduction,intorsion -absent


Left eye- all movements +


Vitals:


Temp-afebrile


PR: 64


RR: 18


BP: 100/60




CVS-s1s2+


RS - BAE+


P/A- soft, non tender




A- 3rd CN palsy with pupillary sparing secondary to TOLOSA HUNT SYNDROME




P-  


1. TAB METHYL PREDNISOLONE 1MG/KG PO/OD


2.TAB PAN 40mg PO/OD


3.INJ HAI s/c acc to grbs


4.VITALS MONITORING 4th hrly


5.INFORM SOS







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